Open revascularization in a patient with chronic mesenteric ischemia and a history of aorto-bifemoral bypass − a case report

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Otevřená cévní rekonstrukce u pacienta s chronickou mezenteriální ischémií a anamnézou implantace aortobifemorálního bypassu − kazuistika

Úvod: Tato kazuistika popisuje chirurgickou léčbu chronické mezenteriální ischemie u polymorbidního pacienta s anamnézou implantace aortobifemorálního bypassu.

Kazuistika: Pacient trpící okluzí mezenteriálních tepen si stěžoval na postprandiální bolesti a váhový úbytek. Endovaskulární léčba nebyla úspěšná. Pacientovi byl úspěšně implantován retrográdní bypass z levého ramínka protézy původního aortobifemorálního bypassu na odstup arteria mesenterica superior.

Závěr: V diskuzi jsou ve zkratce zmíněny aktuální trendy v léčbě tohoto onemocnění. I přes rozvoj intervenční radiologie zůstává chirurgická léčba relevantní alternativou pro management chronické mezenteriální ischemie.

Klíčová slova:

mezenteriální ischemie – periferní bypass

Authors: M. Olexa ¹; K. Lipár ¹; J. Chlupac ^1,2; L. Janousek ^1,3; J. Froněk ^1,2,3
Authors place of work: Department of Transplantation Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic ¹; Department of Anatomy, 2nd Faculty of Medicine, Charles University, Prague, Czech Republic ²; 2nd Faculty of Medicine, Charles University, Prague, Czech Republic ³
Published in the journal: Rozhl. Chir., 2023, roč. 102, č. 5, s. 204-207.
Category: Kazuistika
doi: https://doi.org/10.33699/PIS.2023.102.5.204–207

Summary

Introduction: This case report describes surgical treatment of chronic mesenteric ischemia in a polymorbid patient with the history of an aorto-bifemoral bypass implant.

Case report: The patient suffered from chronic occlusions of the mesenteric arteries. He experienced postprandial pain and significant weight loss. Endovascular repair of the occlusions failed. Open single retrograde bypass from the left branch of the aorto-bifemoral graft to the superior mesenteric artery was implanted successfully.

Conclusion: The discussion briefly mentions current trends in the treatment of chronic mesenteric ischemia. Despite the development of interventional radiology, surgical treatment remains a relevant alternative for the management of chronic mesenteric ischemia.

Keywords:

mesenteric ischemia – peripheral bypass graft

INTRODUCTION

Chronic mesenteric ischemia is a relatively rare and severe condition. Symptoms do not usually appear until at least two of the three mesenteric arteries are significantly affected. Revascularization is indicated for all patients with symptoms of chronic mesenteric ischemia [1].

Endovascular repair is considered the gold standard for treating mesenteric occlusive disease, and it is also preferred in high-risk patients.

The technical complications involved in endovascular procedures increase with the presence of severe eccentric calcification, flush occlusion, longer lesions, small vessels, and tandem lesions affecting branches [2].

This case report is focused on chronic mesenteric ischemia management in a patient with aorto-bifemoral bypass and long medical history.

CASE REPORT

A 66-year-old male patient was referred to our department with symptoms of chronic mesenteric ischemia (CMI). He had lost 13 kg in the previous 5 months and was experiencing postprandial abdominal pain and loss of appetite. The patient had a complicated medical history that included diabetes mellitus, arterial hypertension, and chronic renal insufficiency without hemodialysis. He had also undergone a coronary artery bypass grafting operation as well as abdominal surgery for necrotizing pancreatitis. Due to peripheral arterial occlusive disease, an aorto-bifemoral bypass was implanted. Afterwards, a stent graft was inserted into a proximal anastomotic pseudoaneurysm. This resulted in an occlusion of the inferior mesenteric artery origin.

A prehospital gastroscopy and colonoscopy were performed and turned out negative. A computed tomography angiography (CTA) confirmed the obliteration of the superior mesenteric artery (SMA). Celiac artery was without significant stenosis. Occlusion of the upper right superior renal artery and a significant left renal artery stenosis were among secondary findings. Malnutrition was a dominant clinical sign at the time of admission. Angioplasty and stenting were used to dilate the left renal artery (Fig. 1).

Obr. 1: A) stenóza levé renální tepny, B) uzávěr arteria
mesenterica superior, C) stentgraft v aorto-bifemorálním
bypassu.<br>
Fig. 1: A) left renal artery stenosis, B) superior mesenteric
artery, C) stent graft in aorto-bifemoral bypass — Obr. 1: A) stenóza levé renální tepny, B) uzávěr arteria mesenterica superior, C) stentgraft v aorto-bifemorálním bypassu.
Fig. 1: A) left renal artery stenosis, B) superior mesenteric artery, C) stent graft in aorto-bifemoral bypass

Endovascular repair of the SMA ended in technical failure. Therefore, a single retrograde bypass from the left branch of the aorto-bifemoral graft to the SMA was indicated. The patient was provided with supplemental parenteral nutrition three weeks prior to the procedure. The bypass graft surgery was performed with a C-loop shaped synthetic polytetrafluoroethylene vascular prosthesis (Figs. 2, 3).

Obr. 2: Distální anastomóza<br>
Fig. 2: Distal anastomosis — Obr. 2: Distální anastomóza
Fig. 2: Distal anastomosis

Obr. 3: Proximální anastomóza<br>
Fig. 3: Proximal anastomosis — Obr. 3: Proximální anastomóza
Fig. 3: Proximal anastomosis

There were no perioperative complications. An ultrasound confirmed the patency of the vascular reconstruction. The patient was discharged on postoperative day 8 with a fully recovered digestive tract. A two week follow-up revealed an improvement in the patient’s condition, and after 3 months, a CTA reconfirmed the patency of the reconstruction (Figs. 4, 5).

Obr. 4: A) uzávěr proximálního úseku arteria mesenterica
superior, B) průchodná cévní rekonstrukce.<br>
Fig. 4: A) occlusion of proximal superior mesenteric artery,
B) patent vascular reconstruction — Obr. 4: A) uzávěr proximálního úseku arteria mesenterica superior, B) průchodná cévní rekonstrukce.
Fig. 4: A) occlusion of proximal superior mesenteric artery, B) patent vascular reconstruction

Obr. 5: A) stent v levé renální tepně, B) uzávěr pravé horní
renální tepny, C) nativní cévy, D) aorto-bifemorální bypass
s implantovaným stentgraftem, E) současná cévní
rekonstrukce.<br>
Fig. 5: A) stent in left renal artery, B) occluded right upper
renal artery, C) native vessels, D) prosthetic aorto-bifemoral
bypass with stent graft, E) actual vascular reconstruction — Obr. 5: A) stent v levé renální tepně, B) uzávěr pravé horní renální tepny, C) nativní cévy, D) aorto-bifemorální bypass s implantovaným stentgraftem, E) současná cévní rekonstrukce.
Fig. 5: A) stent in left renal artery, B) occluded right upper renal artery, C) native vessels, D) prosthetic aorto-bifemoral bypass with stent graft, E) actual vascular reconstruction

The patient had no abdominal pain and returned to his normal weight after 6 months.

DISCUSSION

Mesenteric ischemia occurs when perfusion of the bowel fails to meet its normal metabolic requirements [3].

It results from stenotic lesions, most commonly of atherosclerotic origin. These lesions are typically located at the aortic origin of the celiac, superior mesenteric, or inferior mesenteric artery. Between 85 to 100% of cases involve the SMA [4].

Current multidetector row CT, coupled with three-dimensional imaging software, provides an excellent analysis in a non-invasive, rapid manner [4].

The evaluation of the mesenteric fat, vasculature, and surrounding peritoneal cavity also helped to improve diagnostic accuracy [5].

Treatment goals include relieving symptoms, restoring normal weight, and preventing bowel infarction. Prophylactic revascularization in patients with asymptomatic disease is controversial and rarely undertaken [1].

Endovascular repair has surpassed open bypass as the first treatment option, with the SMA being the primary target for revascularization. The role of two-vessel stenting remains controversial to this day. Angioplasty and stenting are ideal for a short, focal stenosis or occlusion with minimal to moderate calcification or thrombus [2].

In our case, a relatively long, heavily calcified flush occlusion of the SMA was present. This is the reason why the previous endovascular procedure failed. The character of the occlusion was also a contraindication of retrograde open mesenteric stenting which may be used as an alternative hybrid approach.

Based on a report by Bulut et al, long-term secondary patencies after percutaneous mesenteric artery stenting are comparable with long-term patencies after open surgical revascularization [6].

Oderich et al preferred stenting for lower-risk groups, and open revascularization in cases where the anatomy is unfavorable for angioplasty. Mesenteric bypass surgery has also been performed on patients who have failed to respond to percutaneous intervention as well as for those with multiple recurrences or other non-atherosclerotic lesions [2].

A variety of open surgical techniques are used to reconstruct the mesenteric arteries. Choice of the procedure is based on the type of incision (transperitoneal vs retroperitoneal), conduit (vein vs prosthetic), graft configuration (antegrade vs retrograde), source of inflow (aortic vs iliac), and number of vessels requiring reconstruction (single vs multiple). The type of open reconstruction is selected based on the anatomy and the clinical risk assessment of the patient. Our patient with an aorto-bifemoral graft and long medical history was in a high-risk group. The patient had undergone previous surgical procedures, including in the area of chronic pancreatitis. That left him with a hostile abdomen. He had only one functioning kidney with the stented artery. Due to previous vascular interventions the patient was only left with the celiac artery. Open antegrade revascularization with suprarenal aorta preparation and partial cross clamping would have been a serious hazard. We also excluded transaortic mesenteric endarterectomy because of similar problems.

As determined by Oderich et al, the iliac artery is also a good source of inflow in high-risk patients or in those who have diseased or calcified aortas [7].

Therefore a single retrograde bypass from the left limb of the aorto-bifemoral graft to the superior mesenteric artery was considered the best option.

Antiplatelet therapy should be initiated following revascularization with concurrent dual antiplatelet therapy considered for 3–12 months, especially after stent placement. It remains unclear whether dual antiplatelet therapy produces better outcomes compared to monotherapy [8].

Open revascularization leads to significant symptom improvement in up to 93% of cases.

The primary patency rate of the open bypass was 89% at 5 years [7].

Quality of life for CMI patients significantly improves after mesenteric artery revascularization [9].

Recent technological advances have resulted in a decrease in the use of open surgical revascularization for treating mesenteric occlusive disease. The procedure is reserved for low-risk patients and those who are not suitable candidates for endovascular repair. In our case, the endovascular procedure failed, and the patient was successfully treated with an open retrograde iliac to mesenteric bypass graft.

Abbreviations:

CMI − chronic mesenteric ischemia

CTA − computed tomography angiography

SMA − superior mesenteric artery

Acknowledgements

The authors would like to thank the endovascular intervention team from IKEM for their valuable efforts and Brian Kavalir for his proofreading services.

Conflict of interests

The authors declare that they have not conflict of interest in connection with this paper and that the article has not been published in any other journal, except congress abstracts and clinical guidelines.

MUDr. Mário Olexa

Vídeňská 1958/9

140 21 Praha 4

e-mail: olxm@ikem.cz

Zdroje

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2. Oderich GS. Mesenteric vascular disease: chronic ischemia. In: Cronenwett JL, Johnston KW, et al. Rutherford’s vascular surgery. 8th ed. Philadelphia, Elsevier Saunders 2014: 2373−2397.

3. Filis K, Galyfos G, Sigala F. Mesenteric vascular disease. In: Catalano M, Pescvarady Z, Wautrecht J-C, et al. VAS European book on angiology/vascular medicine: Reference book for European training, courses and CESMA-UEMS European exam. 1st ed. Roma, Aracne editrice 2018:505−517.

4. LeCroy ChJ, Jordan WD Jr. Visceral artery occlusive disease (Mesenteric occlusive disease). In: Bland KI, Sarr MG, Büchler MW, et al. General surgery. 2nd ed. London, Springer 2009:1828−1836.

5. Dhatt HS, Behr SC, Miracle A, et al. Radiological evaluation of bowel ischemia. Radiologic Clinics of North America 2015;53(6):1241–1254. doi:10.1016/j.rcl.2015.06.009.

6. Bulut T, Oosterhof-Berktas R, Geelkerken RH, et al. Long-term results of endovascular treatment of atherosclerotic stenoses or occlusions of the coeliac and superior mesenteric artery in patients with mesenteric ischaemia. Eur J Vasc Endovasc Surg. 2017; 53(4):583–590. doi: 10.1016/j.ejvs.2016.12.036.

7. Bower TC. Techniques of open mesenteric reconstructions. In: Oderich GS. Mesenteric vascular disease. 1st ed. New York, Springer-Verlag New York 2016:145−156.

8. Gnanapandithan K, Feuerstadt P. Review article: Mesenteric ischemia. Current Gastroenterology Reports 2020;22(4). doi:10.1007/s11894-020-0754-x.

9. Blauw JTM, Pastoors HAM, Brusse-Keizer M, et al. The impact of revascularisation on quality of life in chronic mesenteric ischemia. Canadian Journal of Gastroenterology and Hepatology 2019;2019:1−7. doi:10.1155/2019/7346013.